While much of the world is reopening and life for those vaccinated has returned to a new normal, many nursing home residents are still living under lockdown after lockdown. A single COVID-19 case in a nursing home can trigger a two-week lockdown for all residents—longer if cases have spread—and a return to the isolation that has impacted so many of us throughout the course of last year. Even before the pandemic, there were questions around the quality of care delivered in long term care facilities, but throughout the pandemic the vulnerability of nursing home residents become ever more apparent.
When the pandemic hit, all of us were at risk of infection, but nursing home residents were in a uniquely hazardous position. This was partly because of the communal nature of long term care housing, but also because of how closely residents interact with a rotating cast of caregivers and staff, many of whom care for multiple residents in ways that can easily spread disease, like feeding them or brushing their teeth. Though nursing home residents and staff were among those who needed the most protection in the face of the disease, they were often last on the list of those to receive it. Across the US, there were widespread reports of understaffing and a lack of personal protective equipment in nursing homes, two areas of neglect that were later shown to be key drivers of the spread of COVID-19 in long term care facilities.
The unfortunate result is seen in the lives of those lost—nearly 31 percent, or roughly one-third, of COVID-19 deaths in the US are linked to nursing homes. In five states alone, the number of deaths of nursing home residents due to COVID-19 accounts for either half or more of all recorded fatalities. While the fatality rate for COVID-19 across the US hovers around two percent, in nursing homes the rate is significantly higher, at ten percent. While a reckoning with our failures over the past year may help us improve nursing home care in the years to come, the challenges to delivering higher quality care have only grown.
Nursing home costs have skyrocketed due to the pandemic, with many for-profit homes no longer able to keep up. Demands for personal protective equipment and other needed supplies have driven part of the increases in costs, but the real burden is the demand for additional staff to provide better care. Prior to the pandemic, many nursing homes weren’t meeting Medicare’s minimum staffing requirements, which are undoubtedly one of the key factors in determining a nursing home resident’s quality of care. Now, with the failures of the past year, nursing homes have been asked to not only meet these requirements but ensure there are necessary staff on hand to ensure these requirements are met even when a number of staff are out on sick leave or required to quarantine due to exposure to COVID-19.
In response, some smaller foundations have provided grants to improve the quality of care delivered to patients in long-term living facilities. The Hartford Foundation, for example, recently released a free COVID-19 Rapid Response Network for nursing homes across the United States. This program offers homes that are certified in Medicare and Medicaid programs the opportunity to participate in a training course with immediate access to specific, pragmatic guidance from federal and state policymakers on clinical and operational issues confronting the nursing home community today. The Rapid Response Network includes a twenty-minute National Nursing Home Huddle twice a week. In these meetings, faculty from select nursing homes, government policymakers, and state regulators explore real-time solutions that can be implemented in nursing homes. Some of these include acquiring funding to increase personal protective equipment supply, improve COVID-19 testing methods, and increase staff capacity in individual facilities.
But no matter how well-intentioned, small scale initiatives like the one above can only do so much to solve such a widespread problem. The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) is pushing for an increase in reimbursement rates for nursing home services offered by Medicare and Medicaid. As of 2020, Medicaid remains the primary payer for nursing home care, covering more than sixty percent of all nursing home residents. Medicaid reimbursements, in turn, cover seventy to eighty percent of the total cost of nursing home care, leaving a large gap in funding. As costs rise due to COVID-19, federal payments are falling short of what nursing homes need to provide a higher quality of care. In result, the AHCA/NCAL is asking that Medicaid increase funding to reflect the increasing costs providers are facing by matching the total cost of care.
While Americans wait for changes in the nursing home system, many are choosing to take matters into their own hands and care for their loved ones at home. The pandemic has created an explosion in demand for at-home caregivers, with the workforce expecting to increase by more than a third by 2029. When done correctly, in-home nursing can offer a high quality of life for those in need of care. In a pandemic, in-home care provides better odds for safe visitations with family members and, in caring homes with adequate resources, the most comfort in the final stage of life.
Traditionally, in-home care has been highly undervalued in the United States. With COVID-19, however, this care was the only feasible option for families looking after their seniors. One of the few bright lights in the midst of the pandemic is the attention now being paid to the benefits of home care. In a speech delivered to Congress earlier this year, President Biden committed $400 billion for home care. Much of that money is dedicated to developing and expanding the workforce as the demand for caregivers continues to rise. His speech jolted the attention of the public and increased hopes of shining light on in-home care to better provide for our seniors. Perhaps a sign of hope for the future, born out of the tragedy of this past year.